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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 415601063
Report Date: 11/05/2021
Date Signed: 11/05/2021 12:44:01 PM

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 851 TRAEGER AVE., SUITE 360
SAN BRUNO, CA 94066
FACILITY NAME:MISSION WOODSIDEFACILITY NUMBER:
415601063
ADMINISTRATOR:CONDE, GABRIEL V.FACILITY TYPE:
740
ADDRESS:2028 MARYLAND STREETTELEPHONE:
(650) 554-1000
CITY:REDWOOD CITYSTATE: CAZIP CODE:
94061
CAPACITY:6CENSUS: 4DATE:
11/05/2021
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME BEGAN:
11:55 AM
MET WITH:Laura Paniagua AlvareTIME COMPLETED:
01:00 PM
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On 11/5/2021, Licensing Program Analysts (LPA) Jaime Vado and Komal Charitra conducted an unannounced infection control required 1 year inspection. LPA met with nurse Laura Panaiagua Alvare explained purpose of today's inspection.

LPAs toured facility's building and grounds. Upon entry LPAs were screened for COVID with temperatures taken and COVID related questions asked. LPAs toured facility with Laura. It is suggested that COVID signs be present within facility bedrooms. According to Laura residents rarely leave the rooms and visitors primarily only go to their family member's room. There are no accessible bodies of water or fire safety hazards observed within the facility or in exterior visiting area. Infection control practices are reviewed: entry procedures, staff training and policies, resident monitoring and staff monitoring, containment strategies, environmental preparation and cleaning are in place. Medications, toxins and sharps are stored appropriately and inaccessible to residents. Facility ambient temperature is comfortable and lighting is sufficient for residents and staff safety. Toilet and bathing facilities are equipped with grab bars and non-skid flooring material. Liquid soap is available in resident bathrooms and paper towels are present. Hand washing signs are present. First-aid kit is available on site. There are 4 residents and 2 staff persons present. All staff are wearing masks. Criminal record clearances or exemptions for facility staff or other individuals who have client contact have been reviewed as current. All staff are vaccinated and undergoing booster updates.

The following updated forms are requested to be submitted to CCLD by 11/12/2021:

• LIC 308 Designation of Administrative Responsibility
• LIC 500 Personnel Report
• LIC 610E Emergency Disaster Plan
• LIC400 and LIC402 with copy of current surety bond if needed
• Copy of mitigation
• Updated copy of administrator certificate

No deficiencies cited. Report is reviewed with Laura.
SUPERVISOR'S NAME: Brenda ChanTELEPHONE: (650) 266-8800
LICENSING EVALUATOR NAME: Jaime VadoTELEPHONE: (559) 476-9353
LICENSING EVALUATOR SIGNATURE:

DATE: 11/05/2021
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:

DATE: 11/05/2021
This report must be available at Child Care and Group Home facilities for public review for 3 years.
LIC809 (FAS) - (06/04)
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